Epidural Analgesia for Labour Pain Clinical Guideline V3.1 ...€¦ · and allowed to dry (see AAGBI Safety guideline: skin antisepsis for central neuraxial blockade). If patient

Epidural Analgesia for Labour Pain Clinical Guideline

V3.2

December 2020

Epidural Analgesia for Labour Pain Clinical Guideline V3.2 Page 2 of 19

1. Aim/Purpose of this Guideline 1.1. Epidural analgesia is the most effective form of labour pain relief. It may be

particularly useful for women whose labour is likely to be long or difficult, when operative delivery is likely and in women where general anaesthesia may be challenging, e.g. morbid obesity, likely difficult intubation and cardiac disease. In the first stage of labour, pain from uterine contractions and cervical dilatation is conducted through spinal nerve roots T10-T12 via the paracervical plexus. For the second stage of labour, innervation of the pelvis and perineum is via the pudendal nerve to spinal roots S2-S4. Properties of the ideal labour epidural include:

Provision of sensory blockade adequate for both first and second stages of labour

Avoidance of motor block to enable mobility and pushing and avoid risk of pressure sores

The ability to top up and convert the labour epidural to an operative epidural

A low risk of procedure-related complications

1.2. This version supersedes any previous versions of this document. 1.3. This guideline makes recommendations for women and people who are

pregnant. For simplicity of language the guideline uses the term women throughout, but this should be taken to also include people who do not identify as women but who are pregnant, in labour and in the postnatal period. When discussing with a person who does not identify as a woman please ask them their preferred pronouns and then ensure this is clearly documented in their notes to inform all health care professionals (NEW 2020).

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2. The Guidance 2.1. In practice, the L2/3 or L3/4 interspace is normally used for epidural catheter

insertion and the necessary block achieved by the spread of an appropriate dose and volume of drugs.

2.2. Addition of opioid to the epidural mixture allows the local anaesthetic concentration to be reduced while maintaining good quality analgesia, thus reducing unwanted motor blockade

2.3. A 24 hour epidural service is available. The time from the anaesthetist being

informed of the request for an epidural until they are able to attend the woman should not normally exceed 30 minutes. This should be within an hour except in exceptional circumstances. Reasons for delay should be documented.

2.4. If the delivery suite anaesthetist is unable to attend for an epidural, following

discussion with them regarding their anticipated availability another anaesthetist may be sought via switch. Between 5.30pm and 8pm from Monday to Thursday phone Theatre 7 to discuss with the CEPOD anaesthetist availability from the emergency lists. On Friday 5.30pm to 8pm there is an obstetric anaesthetist on-call from 5.30-8pm as well as the duty obstetric anaesthetist. From 8pm to 8am and at weekends the Senior Anaesthetic Trainee should be contacted.

2.5. Absolute contraindications

Declined by woman

Inadequate midwifery staffing or training

No CTG or inadequate monitoring of fetus

Local infection at proposed site of insertion

Raised intra-cranial pressure

Uncorrected hypovolaemia

Coagulopathy

Anticoagulant therapy

Spina bifida occulta (unless magnetic resonance imaging (MRI) scan shows normal anatomy)

2.6. Relative contraindications

Significant cardiac disease

Some neurological disorders

Some anatomical deformities, surgery or injuries to woman's back

Sepsis

Suspicious or pathological CTG which has not had obstetric review

2.7. Conditions where epidural analgesia is more likely to be indicated

Pre-eclampsia

Prolonged labour

Multiple gestation

Anticipated instrumental delivery

Cardiac and respiratory disease

Obesity


2.8. Sepsis and epidural analgesia Epidural abscess formation is a rare but serious complication of epidural analgesia. Abscess formation complicates around 0.2–3.7 per 100,000 obstetric epidurals, while bacterial meningitis is more common after spinal and combined spinal-epidural techniques, with an incidence not exceeding 1.5 in 10,000. For further information on sepsis see RCHT guideline Sepsis: Recognition and Management of Antenatal and Postnatal Sepsis – Clinical Guideline.

2.9. Midwifery checks prior to epidural

Ensure midwife is trained in epidural management (on-line training booked on ESR)

Provide the Obstetric Anaesthetist Association (OAA) fact sheet of risks (available in foreign languages) and document discussions and consent. See www.labourpains.com

Cannulate and commence fluid

Ensure at least 20 minutes of normal CTG has been obtained and continue monitoring

Check blood test results if coagulopathy suspected

SBARD style communication to anaesthetist

Commence fluid balance chart

Record a pre-insertion heart rate, blood pressure, temperature and Fetal Heart Rate (FHR)

Check pressure areas including FSE attachment on leg if applicable.

2.10. Consent

2.10.1. However distressed the mother may be in labour, verbal consent must be obtained before undertaking epidural analgesia.

2.10.2. Consent for an epidural must be documented on the epidural form. 2.10.3. Women should be given the OAA epidural information card to read

prior to discussion with the anaesthetist (Appendix 3). This information is available in a number of different languages and can be printed out from www.labourpains.com from the translations tab.

2.10.4. Complication risks and their frequency of occurrence should be

discussed in line with the information from the OAA.

2.10.5. The extent to which all potential complications are discussed will depend on individual circumstances, but the following risks must be explained:

Incomplete analgesia (incidence up to 1:5) and possible need to re-site epidural (about 5%)

Motor block

Drop in blood pressure

Headache due to accidental dural puncture (incidence 1 in 100)

Nerve injury both temporary (~1:1,000) and permanent (~1:13,000)

Risk of infection (1:50,000) or haematoma (1:170,000)

http://www.labourpains.com/


2.10.6. You should consider discussing the following if appropriate:

A possible association with a higher rate of operative delivery. This remains controversial and is less evident with the use of low-dose epidural infusions.

Urinary retention

Good evidence that there is no association with long-term backache

2.11. Preparation The following measures must be taken before epidural insertion:

OAA Epidural information card seen by patient

History taken to confirm no contraindications

Platelets should be >80, INR <1.4

Check thromboprophylaxis state

Maternal consent

Measure blood pressure

Establish large bore IV access (16G)

Position patient in either the lateral or sitting position

Full aseptic precautions – gown, gloves, hat and face-mask

Preparation of the area with 0.5% Chlorhexidine spray away from epidural kit and allowed to dry (see AAGBI Safety guideline: skin antisepsis for central neuraxial blockade). If patient allergic use an 10% povidone iodine solution

Infiltration of the skin and superficial layers with local anaesthetic.

2.12. Thromboprophylaxis 2.12.1. Neuraxial block should not be sited within 12 hours of administration of

up to 5000 units of Low molecular Weight Heparin (LMWH) and more than 24 hours if greater than 5000 units

2.12.2. Careful consideration should be given to obese women on higher

doses of prophylactic LMWH. See the Association of Anaesthetists of Great Britain and Ireland (AAGBI) guideline 'Regional anaesthesia and patients with abnormalities of coagulation' as there is a spectrum of risk

2.12.3. Chlorhexidine may cause serious neurological damage if in

contact with neuraxial structures.

2.12.4. Apply to the skin prior to preparation of epidural/spinal equipment.

2.13. Labour Epidural Technique

2.13.1. Loss of resistance to saline should be used

2.13.2. 3–5 cm of catheter should be left in the epidural space. Leave 1-2 cm more if obese. Be mindful that sometimes, especially in the obese, when the woman extends the back after being positioned for epidural insertion, the catheter may migrate in.

2.13.3. Secure with a Lockit™ and adequate sterile dressings


2.13.4. Aspirate catheter for blood and CSF prior to first dose

2.13.5. If catheter is intrathecal see RCHT guideline for 'Management of Accidental Dural Puncture'.

2.13.6. Attach the giving set to the 250ml 0.1% levobupivacaine + 2mcg/mL

fentanyl bag, prime the set and connect to the epidural filter. This is the responsibility of the attending anaesthetist.

2.13.7. A test dose of 8 mg bupivacaine should be given – Give this using the

low dose mix i.e. 8ml of bupivacaine 0.1% +2 mcg/ml fentanyl through the epidural pump as a Clinician Bolus and delay the Autobolus start (this will then start 60 minutes later).

2.13.8. Following the test dose, check maternal blood pressure and confirm

the absence of motor block and rapid resolution of pain due to intrathecal administration.

2.13.9. Give a further 7ml of low dose mix via the epidural pump using a

Clinician Bolus (15 ml in total).

2.13.10. The maternal pulse rate (PR), blood pressure (BP) and fetal heart rate (FHR) are recorded every 5 mins for 20 mins and recorded on the epidural observation chart.

2.13.11. Prescribe the epidural protocol on EPMA and prescribe fluids.

2.13.12. Document epidural insertion on Euroking under obstetric anaesthetic

procedure and epidural chart.

2.13.13. Return in 10 – 15 minutes to assess the quality of the epidural block

2.13.14. There is evidence that reducing pain whilst maintaining motor function improves both maternal satisfaction and the outcome of labour. By avoiding high concentrations of local anaesthetic, motor block is minimised, cardiovascular instability reduced and the ability to push in the second stage maintained.

2.14. Inadvertent Intravenous (IV) placement

2.14.1. Be aware of signs of local anaesthetic toxicity these may include: Light headedness, circumoral tingling, tinnitus, odd taste in mouth, seizures, cardiovascular collapse

2.14.2. If you suspect an IV catheter do not use it, call for senior help and

consider re-siting epidural.

2.14.3. Refer to AAGBI guideline 'Management of Severe Local Anaesthetic Toxicity'

For epidural analgesia in labour, minimise motor block by using the low-dose mix of 0.1% levobupivacaine with

2 mcg/ml fentanyl wherever possible


2.15. Patient Controlled Intermittent Epidural Bolus Pump setup Automatic bolus: 7 mls 0.1% Levobupivacaine and 2mcg/ml Fentanyl Automatic bolus interval: 60 minutes PCEA bolus: 6 mls 0.1% Levobupivacaine and 2mcg/ml Fentanyl PCEA lockout: 20 minutes

2.15.1. The anaesthetist is responsible for priming and setting up the epidural

pump. See laminated sheet attached to epidural pump for setting up the pump.

2.15.2. An explanation of how the pump works to the woman and her birth

partner is essential to ensure that the epidural has the best chance of success. This should be done after the initial top-up has had a chance to work.

2.15.3. Epidural top-ups for labour analgesia can be done by stopping the

pump and selecting a Clinician Bolus of the epidural mixture. This is typically 5 mls of 0.1% Levobupivicaine plus 2mcg/ml fentanyl followed by a further 5 mls if required. A clinician level 2 code is required for this. 0.25% Levobupivacaine can be given but this requires disconnection of the pump and therefore should be avoided if possible. Boluses should be given only by the attending anaesthetist and not the midwife.

2.16. Protocol for the provision of labour analgesia using Programmed

Intermittent Epidural Bolus (PIEB) 2.16.1. Following the initial bolus from the anaesthetist as above, the blood

pressure and fetal heart rate are checked at least every 5 minutes for 20 minutes.

2.16.2. Once a satisfactory block has been established and the observations

are stable, analgesia is maintained using PIEB.

2.16.3. A 250ml bag of pre-mixed solution of 0.1% bupivacaine with 2mcg/ml fentanyl is supplied by pharmacy. A patient identification sticker must be put on the epidural mix to ensure accurate documentation of any discarded epidural mix in the controlled drugs book (NEW 2020). The anaesthetist should connect the epidural solution to the pump.

2.16.4. The PIEB pump has two functions:

The pump is programmed to provide a mandatory automatic bolus of 7mls of pre-mixed solution every hour.

A supplemental patient controlled bolus, Patient Controlled Epidural Analgesia (PCEA) of 6mls of pre-mixed solution can be given by the patient via the handset. This has a programmed 20 minute lock-out to avoid inadvertent over-dosing. The PCEA handset is to be given to the patient 20 minutes after the epidural has been started.

2.16.5. If the PCEA is used there is an automatic delay of 20 minutes before

the next PIEB. After the PIEB is given the PCEA is locked out for 20 minutes.


2.16.6. For the duration of the epidural use the midwife should record: Blood pressure every 30 minutes. If the systolic BP falls to 90mmHg or below then the following should be considered:

500mls Hartmann’s solution

Positioning the patient in the left lateral position

Stop the epidural pump

Raise the patient’s legs appropriately

2.16.7. If these manoeuvres do not restore the BP the anaesthetist must be called.

2.16.8. Count and chart the respiratory rate. If the rate is less than 10 call the

anaesthetist for immediate review using SBARD format.

2.16.9. Document the amount of patient movement using the modified Bromage score. If the score is 2 or more contact the anaesthetist. Bromage Score: 0 = Normal movement 1 = Just flex knee, feet move normally 2 = Unable to move knee, feet move normally 3 = Unable to move legs or feet

2.16.10. Document the volume infused of the pre-mixed solution every hour.

2.16.11. Measure and chart the block height every hour referring to the

dermatome chart. It should ideally be T8-T11 bilaterally.

2.16.12. Ensure that the patient’s bladder is empty 4 hourly during labour, catheterising if necessary.

2.16.13. Check pressure areas hourly as per epidural chart. FSE attachments

should be moved to alternate legs every 6 hours.

2.16.14. Level of block

Above T4 Stop pump immediately and call anaesthetist using SBARD format

T4 – T8 Call anaesthetist to review protocol

T8-T11 Leave unchanged

Below T11 and in pain Call anaesthetist

2.16.15. If the block is unilateral, turn the patient to improve the block height on

the dependant side. If there is persistent pain due to a unilateral block or a missed segment call the anaesthetist.

2.16.16. Epidural clinician bolus:

2.16.16.1. If the block height and pain relief is inadequate there is an option for an additional clinician bolus. This should only be administered by the anaesthetist.


2.16.16.2. Following a clinician bolus the midwife should measure the BP and fetal heart rate every 5 minutes for 20 minutes and document on the chart.

2.16.17. Inadvertent spinal:

If the BP falls markedly or the level of the block increases by four dermatomes in an hour, or the patient has marked leg weakness as assessed by the Bromage Score, this may be due to an inadvertent spinal block. Manage as follows:

Keep the patient in the left lateral position

Run in a litre of Hartman’s as fast as possible

Turn off the epidural pump

Call the anaesthetist

Give oxygen

2.17. Anaesthetist Troubleshooting Inadequate Epidural Analgesia 2.17.1. If the anaesthetist is asked to review an inadequate epidural block,

assess the distribution of the block and observe the woman during a contraction to try to establish a possible cause and solution.

2.17.2. Consider also the parity of the woman, stage of labour and likelihood

of subsequent intervention.

2.17.3. Improvements in pain relief can sometimes be achieved with simple manoeuvres including changing the position of the woman and withdrawing the epidural catheter rather than immediately administering a higher dose of local anaesthetic. 2.17.3.1. No effect of epidural dose on labour pain – if after the

first dose of low-dose mix there is no effect on pain and no demonstrable sensory block after 20 minutes, the catheter is unlikely to be correctly sited in the epidural space. Discuss with the woman and re-site the epidural if still indicated.

2.17.3.2. Missed segment – lie the woman affected side down and

give a bolus of 10 ml low-dose mix (e.g. 10 ml 0.1% bupivacaine + 2mcg/ml fentanyl) or 5 +5 ml 0.25% bupivacaine. If no improvement manage as for unilateral block.

2.17.3.3. Unilateral block – withdraw the catheter by 1 – 2 cm and

give a further dose of low-dose mix (e.g. 10 ml 0.1% bupivacaine + 2mcg/ml fentanyl) with the woman lying with the affected side down. If this fails to improve pain relief consider re-siting the epidural.

2.17.3.4. Patchy block – consider a top-up with fentanyl 50-100 mcg

in 10 ml 0.9% sodium chloride to improve spread. A stronger dose of local anaesthetic (see above) may also be required. Consider the possibility of a subdural block (see below).


2.17.3.5. Persistent perineal pain – consider giving a bolus of fentanyl 50-100 mcg or clonidine 50-75 mcg and/or a sitting bolus top up of 5-10mls 0.25% Levobupivicaine.

2.17.3.6. Pain breaking through a good epidural block – consider

the possibility of uterine scar rupture in women labouring with a previous caesarean section scar. Assess vital signs and request obstetric review.

2.18. Important Points

2.18.1. If the above troubleshooting approaches fail to establish adequate analgesia, the epidural should be re-sited.

2.18.2. Poor regional analgesia in labour predicts poor surgical anaesthesia

should the epidural be topped up. Have a low threshold for re-siting a poorly performing epidural, for example: in women at risk of caesarean section, in women where caesarean under general anaesthesia may be problematic (e.g. obesity, difficult intubation) or women where optimal pain relief in labour is necessary e.g. cardiac disease.

2.18.3. Women with an epidural are at higher risk of operative delivery and

should be reviewed so any problems with the block can be identified early and potentially rectified.

2.18.4. A low risk parturient with an epidural can have a light diet (NEW 2020).

2.18.5. If labour becomes complicated in any way, the mother becomes a high

risk patient and should be nil by mouth but may drink free fluids. The woman can have water and isotonic drinks only (NEW 2020). High risk parturients include:

Multiple pregnancy

Breech

Meconium stained liquor

Slow progress, as defined in by the obstetric guidelines

Oxytocin augmentation

Suspicious or abnormal CTG

FGR

Prematurity less than 36/40

APH

Previous Caesarean Section

Pregnancy induced hypertension/pre-eclampsia (moderate to severe)

Medical illness: such as cardiac disease

BMI >35

Diabetes

2.19. Bloody Tap 2.19.1. If there is blood from Tuohy needle after removal of stylet reinsert in

different interspace.


2.19.2. If blood through the catheter, then withdraw 1cm and then flush with Saline until no further blood appears on aspiration, if sufficient catheter remains in space proceed cautiously with test dose.

2.19.3. If blood is still seen re-site epidural at a different interspace. LMWH

should not be given for 12 hours following a bloody tap through the Tuohy needle.

2.20. Total spinal 2.20.1. Signs include: high sensory level, bradycardia, hypotension,

respiratory inadequacy and loss of consciousness.

2.20.2. Call for help

2.20.3. Reassure and talk to woman

2.20.4. Left lateral position, 100% oxygen, may need to assist ventilation with BMV

2.20.5. Treat respiratory compromise with RSI GA and IPPV. Maintain

anaesthesia and ventilation until local anaesthetic has worn off

2.20.6. Treat hypotension with fluid and vasopressors

2.20.7. Treat bradycardia with an anti-muscarinic agent e.g. Atropine or Glycopyrolate

2.20.8. Consider delivery of the baby so involve obstetrician early

2.21. Subdural Block

2.21.1. An epidural catheter may rarely cause separation of the arachnoid mater from the dura and enter the subdural space. Characteristics of a subdural block include:

An unexpectedly high level of sensory block, sometimes as high as the cervical dermatomes, occurring over 20-30 min after a top-up

Sensory block may be patchy, often with missed segments and persisting pain

Nasal stuffiness and Horner’s syndrome can develop

Motor block is often minimal

2.21.2. Since the arachnoid is thin and easily torn, a subdural catheter may rupture through this layer following a bolus dose and a subdural block may become a spinal block, which may result in a high regional block.

2.21.3. Have a high index of suspicion for a block with a ‘bizarre’ distribution.

Seek advice and re-site the epidural at a different level.

2.21.4. If the catheter appears to be subarachnoid this should be clearly marked and explained to the patient. It can be used throughout labour but the anaesthetist must give all top-up doses. See guidance under management of dural tap.


2.22. Epidurals sited before established labour In view of potential complications associated with prolonged use, an epidural should only be sited prior to established labour;

after alternative pain relief options have been considered

discussion at senior anaesthetic and obstetric level

careful discussion with the woman

requires careful monitoring as they could be in-situ for an extended time frame

Increased risk of misplacement

Increased period of immobility

Pay particular attention to IV fluid regimen and monitor fluid balance closely

2.23. Use of epidural for operative procedures An epidural may be topped up for instrumental delivery, caesarean section, manual removal of placenta and tear repairs.

Establish current block level

Ensure sitting or wedged left lateral position

Top up in increments with 0.5% Levobupivicaine or preservative free 2% Lidocaine to achieve desired block e.g. 20ml 0.5% Levobupivicaine to achieve T4 for caesarean section

The block may be enhanced by adding fentanyl 50-100mcg

Only use epidural if it has been working well, perform spinal if in any doubt

For extended post op analgesia add preservative free morphine 2mg or Diamorphine 3mg post delivery

2.24. Removal of the epidural catheter after delivery:

2.24.1. Epidural analgesia should be continued until after completion of the 3rd stage and any necessary perineal repair. The epidural catheter can be removed once the 3rd stage has been completed, cardiovascular stability confirmed, and there is no evidence of any bleeding. Occasionally the anaesthetist may ask that the epidural catheter is removed later either at a specific time or when requested.

2.24.2. The time of the final bolus and the time of removal of the epidural catheter should be recorded in the patient notes and on the epidural chart.

2.24.3. The Bromage score should be completed at removal of the epidural catheter, at 1 hour post removal and 4 hours post removal. This should be documented on the Intentional Round checklist.

2.24.4. Women should not mobilise unless the Bromage score is zero.

2.24.5. Timing of removal is especially important in women who have been

receiving or will be requiring low weight molecular heparin for thromboprophylaxis. The anaesthetist should give clear written and verbal instructions.

2.24.6. The tip of the epidural should be inspected for the ‘blue tip’ to show it

is complete. This should be documented, together with the time of


removal in the intrapartum record. If removed in the operating theatre after a procedure this should also be recorded.

2.24.7. The mobility assessment should be done by the midwife caring for the

woman and recorded in the intrapartum document. If the woman has passed mobility assessment she should then be encouraged to mobilise.

2.25. Follow up

2.25.1. All women and neonates suitable for a 6 hour discharge are able to continue with early discharged as planned following epidural insertion and removal.

2.25.2. All women should receive information about when and how to seek

help if complications should arise.

2.25.3. All women will need to have voided normally before discharge.

2.25.4. Complaints that should be reported to the anaesthetist immediately eg. headache, severe backache, numbness or weakness in the legs more than 3 hours following removal of an epidural catheter.

2.25.5. All women who remain as inpatients should be followed up by the duty

anaesthetist within 24 hours and this should be documented on Electronic notes.

2.25.6. Women who have complications arising from epidural analgesia are

followed up while inpatients.

2.26. Low-dose Combined Spinal Epidural technique for labour 2.26.1. A low-dose CSE may be appropriate in some circumstances to

establish rapid onset of pain relief in women who are nearing the end of the first stage of labour or who are unable to lie still to allow an epidural to be safely inserted.

2.26.2. A low dose CSE can be performed in the delivery room by placing a

single shot low dose spinal (25G Whitacre needle) followed by an epidural once the woman is comfortable.

2.26.3. Alternatively, a needle-through-needle technique can be used. A dose

of 1ml 0.25% Levobupivicaine or 2 mls of the epidural mix (0.1% levobupivicaine + 2mcg/ml fentanyl).

2.26.4. Note with the above CSE techniques the epidural catheter is not

tested since a spinal block is provided first. The anaesthetist must test the catheter and give the first epidural dose e.g. 8ml low-dose mix (0.1% bupivacaine +2mcg/ml fentanyl).

2.26.5. Whenever injecting drugs intrathecally be cautious both in sterility and

in preparation of correct dose.


2.26.6. Low-dose spinal anaesthesia as described above is unlikely to cause a significant fall in BP or a motor block.

2.26.7. Spinal doses higher than those detailed above must not be

administered outside the operating theatre.

2.26.8. Experience from centres that perform high numbers of low-dose labour CSEs suggest that complications are no higher than when labour epidurals are routinely performed – including the risk of PDPH or intrathecal migration of the epidural catheter.

3. Monitoring compliance and effectiveness Element to be

monitored

100% of women receiving an epidural have had at least 20 minutes

of normal CTG or an Obstetric review if non-reassuring or

abnormal

A woman is seen within 30 minutes of a request for an epidural,

if this is not achieved the reasons why are documented in the

woman’s notes

Lead Obstetric Anaesthetist Lead Consultant

Tool Case notes used for audit and data inputted onto a

spreadsheet to calculate % compliance

Frequency This should be monitored every 2 years

Reporting

arrangements

The audit results will be received at the Maternity Patient

Safety Forum and Clinical Audit Meeting

Acting on

recommendations

and Lead(s)

It deficiencies are identified, an action plan will be developed

and monitored through the group

Change in

practice and

lessons to be

shared

As per the action plan

4. Equality and Diversity

4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Inclusion & Human Rights Policy' or the Equality and Diversity website.

4.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2.

http://www.rcht.nhs.uk/GET/d10268876

http://www.rcht.nhs.uk/GET/d10268876

http://intranet-rcht.cornwall.nhs.uk/shelf/equality-and-diversity/


Appendix 1. Governance Information

Document Title Epidural Analgesia for Labour Pain Clinical Guideline V3.2

This document replaces (exact title of previous version):

Epidural Anaesthesia for Labour Clinical Guideline V3.1

Date Issued/Approved: 4th June 2020

Date Valid From: December 2020

Date Valid To: February 2023

Directorate / Department responsible (author/owner):

Helen King, Consultant Anaesthetist

Contact details: 01872 252361

Brief summary of contents

To give guidance to obstetric anaesthetists, obstetricians and midwives on when an epidural can be offered and the process of administrating an epidural in labour.

Suggested Keywords: Analgesia, dural, epidural, labour, sepsis, spinal, pain, tap, anaphylaxis

Target Audience RCHT CFT KCCG

Executive Director responsible for Policy:

Medical Director

Approval route for consultation and ratification:

Maternity Guidelines Group Care Group

General Manager confirming approval processes

Mary Baulch

Name of Governance Lead confirming approval by specialty and care group management meetings

Caroline Amukusana

Links to key external standards None

Related Documents:

AAGBI/ OAA Guidelines for obstetric

anaesthetic services (2013)

OAA epidural information card (www.oaa-

anaes.ac.uk)

Nice Guidelines CG190 Intrapartum care

(2014)

AAGBI Best practice in the management of

epidural analgesia in the hospital setting

http://www.oaa-anaes.ac.uk/

http://www.oaa-anaes.ac.uk/


92010)

The 3rd National audit project (NAP3) Royal

College of Anaesthetists

Sepsis in obstetrics and the role of the

anaesthetist

D.N. Lucas,a P.N. Robinson,a M.R. Nelb

Department of Anaesthesia, Royal Devon

and Exeter Hospital.

Training Need Identified? Yes

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only

Document Library Folder/Sub Folder

Clinical / Midwifery and obstetrics

Version Control Table

Date Version

No Summary of Changes

Changes Made by

(Name and Job Title)

10 Jun 10 V1.0 Initial issue Rebecca Brooks

Obstetric Anaesthetist

21st May

2015 V1.1

Merged guidelines: Septic Patient – Insertion of

Epidurals and Spinal Anaesthesia & Epidural

Analgesia in Labour

Now includes guidance on epidural insertion in

the septic patient

Rebecca Brookes

Obstetric Anaesthetic

17th May

2018 V2.0

Full review 2.2, 2.2.12, 2.2.13, 2.7 updated. See

new 2018

Rebecca Brooks and

Helen King. Obstetric

Anaesthetists

December

2019 V3.0

Full review and update with RD & E guidelines.

2.18.4 added around high risk women in labour

Helen King, Consultant

Anaesthetist and

Sam Banks, Consultant

Anaesthetist


June 2020 V3.1

1.3.0. Addition of inclusion statement.

2.16.3 Addition of patient identification sticker to

epidural mix.

2.18.4 Addition of light diet for low risk

parturient.

2.18.5 Addition of nil by mouth if complications

except water and isotonic drink.

Updated Trust templates

Rachel Mullins

Practice Development

Midwife

December

2020 V3.2

2.24.2. Addition of recording time of final bolus

and time of removal of epidural.

2.24.3. Addition of recording Bromage score at

removal of epidural catheter, at 1 hour post

removal and 4 hours post removal.

2.24.4. Addition of women should not mobilise

unless Bromage score is 0.

Katharine Sprigge,

Consultant Anaesthetist

Sally Nash, Consultant

Anaesthetist

All or part of this document can be released under the Freedom of Information

Act 2000

This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing

Controlled Document

This document has been created following the Royal Cornwall Hospitals NHS Trust Policy for the Development and Management of Knowledge, Procedural and Web

Documents (The Policy on Policies). It should not be altered in any way without the express permission of the author or their Line Manager.


Appendix 2. Initial Equality Impact Assessment

Section 1: Equality Impact Assessment Form

Name of the strategy / policy /proposal / service function to be assessed Epidural Analgesia for Labour Pain Clinical Guideline V3.2

Directorate and service area: Obstetrics and Gynaecology

Is this a new or existing Policy? Existing

Name of individual/group completing EIA Julie Walton

Contact details: 01872 252361

1. Policy Aim Who is the strategy / policy / proposal / service function aimed at?

To give guidance to obstetric anaesthetists, obstetricians and midwives on when an epidural can be offered and guidance on the process of administrating an epidural in labour.

2. Policy Objectives Safe administration of epidural analgesia in labour, improved maternal experience and maternal outcome.

3. Policy Intended Outcomes

Safe administration of epidural analgesia in labour, improved maternal experience and maternal outcome.

4. How will you measure the outcome?

Audit

5. Who is intended to benefit from the policy?

All women who are considering or having and epidural in labour

6a). Who did you consult with?

b). Please list any groups who have been consulted about this procedure.

Workforce Patients Local groups

External organisations

Other

x

Please record specific names of groups: Maternity Guideline Group Care Group

c). What was the outcome of the consultation?

Guideline Agreed


7. The Impact Please complete the following table. If you are unsure/don’t know if there is a negative impact you need to repeat the consultation step. Are there concerns that the policy could have a positive/negative impact on:

Protected Characteristic

Yes No Unsure Rationale for Assessment / Existing Evidence

Age x All women considering or having an epidural in labour

Sex (male, female non-binary, asexual etc.)

x All women considering or having an epidural in labour

Gender reassignment x All women considering or having an epidural in labour

Race/ethnic communities /groups


Disability (learning disability, physical disability, sensory impairment, mental health problems and some long term health conditions)


Religion/ other beliefs x All women considering or having an epidural in labour

Marriage and civil partnership x All women considering or having an epidural in labour

Pregnancy and maternity x All women considering or having an epidural in labour

Sexual orientation (bisexual, gay,

heterosexual, lesbian) x All women considering or having an epidural in labour

If all characteristics are ticked ‘no’, and this is not a major working or service change, you can end the assessment here as long as you have a robust rationale in place.

I am confident that section 2 of this EIA does not need completing as there are no highlighted risks of negative impact occurring because of this policy.

Name of person confirming result of initial impact assessment:

Katharine Sprigge

If you have ticked ‘yes’ to any characteristic above OR this is a major working or service change, you will need to complete section 2 of the EIA form available here: Section 2. Full Equality Analysis For guidance please refer to the Equality Impact Assessments Policy (available from the document library) or contact the Human Rights, Equality and Inclusion Lead [email protected]

http://doclibrary-rcht-intranet.cornwall.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/ChiefExecutive/Templates/Section2FullEqualityAnalysis.docx

mailto:[email protected]